New York Public Employee Retirement System Special Durable Power Of Attorney (Page 4 of 6) in pdf

New York Public Employee Retirement System Special Durable Power Of Attorney Page 4

executed copy or facsimile of this instrument may act hereunder, and that revocation or

termination hereof shall be ineffective as to such third party unless and until actual notice or

knowledge of such revocation or termination shall have been received by such third party, and I

for myself and for my heirs, executors, legal representatives and assigns, hereby agree to

indemnify and hold harmless any such third party from and against any and all claims that may

arise against such third party by reason of such third party having relied on the provisions of this

instrument. This Special Power of Attorney may be revoked by me at any time.

(j) SIGNATURE AND ACKNOWLEDGMENT:

In Witness Whereof I have hereunto signed my name on __________________________,20___.

PRINCIPAL signs here:

==>___________________________________________________________

(ACKNOWLEDGMENT)

State of …………………………….)

) ss:

County of …………….....................)

On the ………..day of …………….in the year ………….before me, the undersigned, personally

appeared…………………………………………, personally known to me or proved to me on

the basis of satisfactory evidence to be the individual whose name is subscribed to the within

instrument and acknowledged to me that he/she executed the same in his/her capacity, and that

by his/her signature on the instrument, the individual, or the person upon behalf of which the

individual acted, executed the instrument.

……………………………………………………

………………………

Signature of Notary

Expiration Date

(k) SIGNATURES OF WITNESSES: By signing as a witness, I acknowledge that the

principal signed this instrument in my presence and the presence of the other witness, or that the

principal acknowledged to me that the principal’s signature was affixed by him or her or at his or

her direction. I also acknowledge that the principal has stated that this instrument reflects his or

her wishes and that he or she has signed it voluntarily. I am not named herein as a permissible

recipient of the principal’s benefits from a public retirement system.

_________________________________

___________________________________

Signature of witness 1

Signature of witness 2

_________________________________

____________________________________

Date

New York Public Employee Retirement System Special Durable Power Of Attorney Page 4